research
Current Projects
A Multilevel Prospective Study of the Determinants and Outcomes of Child Health and Development in Orange County, Florida
The proposed National Children’s Study of multiple cohorts of children in Orange County, Florida permits one to examine the interplay of genetic information with maternal and child exposure to environmental pathogens that precede the manifestation and detection of adverse effects on child development and health. The Study also enables one to determine the relative importance of specific etiological factors associated with the epidemiological trilogy-- the agent, host, and environment factors -- in accounting for the variation in childhood development and health outcomes. Finally, the Study makes it possible
- to explore the causal sequelae of genetically transmitted health disorders and their disabling effects on children’s physical, mental, and social functions at different developmental stages,
- to identify the change patterns of physical, psychological and social development in the span of 21 years,
- to delineate the effects of both time-invariant (constant) and time-varying predictors on the trajectories of child growth, development, and health status, and 4) to build a child health informatics system to monitor the impact of environmental exposures and guide future interventions and outcome improvement efforts. The proposal is under review by NICHD, NIH.
Modeling the Effects of Organizational Innovations and Medical Technology Adoption on Hospital Performance
The purpose of this project is to investigate hospitals’ operational performance in a changing environment. The contingency-organizational perspective is used to examine the mediating effect of organizational innovation and medical technology adoption on hospitals’ effectiveness and efficiency. This project will validate the measurement of efficiency and effectiveness and will examine the structural relationships among the three components of the health care system. The longitudinal analysis of the change trajectory in hospital performance will be performed. Valuable information generated from a confirmatory analytical approach will identify ways to improve hospital performance.
Preventive Breast Cancer Screening and Examination: Educational Intervention and Evaluation
Little is known about the low screening rate and preventive health behaviors of Korean women living as a minority population. This study will investigate individual and societal factors that influence the variation in preventive practices for breast cancer in two minority groups of Korean women, living in the United States and in the Republic of Kazakhstan. Two interventions (dissemination of preventive educational materials and nurse practitioners’ preventive instruction) are proposed for evaluation of their effectiveness and outcomes. A quasi-experimental design is formulated for each of the two locations of Korean women in the sample:
- the first experimental group will receive preventive educational materials for breast cancer;
- the second experimental group will receive both educational materials and guided instruction for breast cancer screening and examination by nurse practitioners; and
- the third group will be a comparison/control group. An initial survey will be conducted of the knowledge, attitudes, and preventive practices about breast cancer among the study’s 1,500 participants (750 Korean Americans and 750 Korean Kazakhs). Educational interventions will target those (approximately 525 women in each population group) who have not had breast cancer examination/screening. A post-test or follow-up survey of the participants will be conducted within twelve months. The data will be analyzed by covariance structure analysis with multiple groups. The comparative structure of the study should provide valuable insights into the importance and possible means of adapting delivery of preventive care to be effective in a variety of cultural contexts.
Evidence-Based Nursing Home Practice for Improving Facility
Performance and Resident Outcomes in
Thomas T.H. Wan, Ph.D., M.H.S.
Professor and Director
Public Affairs Doctoral Program
Telephone: 407-823-3678
Fax number: 407-823-0744
Email address: twan@mail.ucf.edu
Co-Investigators:
Jackie Zhang, MD, Ph.D. (health services research)
Lynn Unruh, Ph.D. (health economics)
Kenneth Adams, Ph.D. (Criminal Justice)
Patrick McNees, Ph.D. (Geriatric outcomes research)
Denise Gammonley, Ph.D., L.C.S.W. (social work)
Maxime Gagnon, Ph.D. (Gerontology and psychology)
Aaron Liberman, Ph.D. (Healthcare finance)
Allan March, MD (healthcare informatics research)
Executive Summary
The proposed collaborative project consists of six areas of research investigation on the quality of nursing homes in
1. Predictors of the Best Quality Practice in Nursing Homes in
A GIS Application
Investigators:
Thomas T.H. Wan, Ph.D., UCF
Jckie Zhang, Ph.D., UCF
Lynn Unruh, Ph.D.,UCF
Abstract
This is a confirmatory study of the determinants of the best quality practice in nursing homes. Predictors include nurse staffing, rehabilitation orientation, organizational factors, and contextual factors such as market and area characteristics. The quality score card approach is employed to identify the top 10 percentile of high quality facilities for each of the eight years (1997-2004) in the
2. Balanced Scorecard Approach to Benchmarking Nursing Home Performance in
Investigators: Thomas T. H. Wan, PhD; Ning Jackie Zhang, MD, PhD; Lynn Unruh, PhD, RN; Aaron Liberman,,Ph.D.
With the increasing market competition, declining of government reimbursement, and aging of population, nursing homes have difficulties maintaining their operation and trying to find effective strategies to remain financially viable. Under theses circumstances, it is hard for nursing homes to perform efficiently and achieve desirable quality and resident outcomes. Therefore, complaints and lawsuits on nursing home negligent care rose in recent years. Improving nursing home performance becomes one of the top priorities of long term care research. The balanced scorecard (BSC) framework developed by Kaplan & Norton (1993) allows researchers to measure and benchmark facilities’ performance and develop strategies to improve the performance.
The aims of the study are: 1) benchmark the efficiency, quality and resident outcomes of nursing homes in Florida, using national nursing home data and balanced scorecard approach; and 2) explore personal, organizational, and market factors influencing the variation in nursing home performance.
This is a longitudinal panel study. Eight years’ national data on nursing home facility deficiencies (OSCAR data, 1997-2004), nursing home resident outcomes (MDS data, 1998-2002), nursing home cost reports (cost report data), and other administrative/investigative data will be used to benchmark nursing home performance in three major areas, quality, efficiency, and safety. Cumulative scores on yearly performance will be assigned to facilities to generate the relative performance rankings. The performance being evaluated in the BSC includes: facility technical efficiency (production efficiency), risk-adjusted nursing home quality (deficiencies), risk-adjusted resident outcomes, and customer (resident and the family) satisfaction. Resident satisfaction data will be collected by a face-to-face survey with 20% random sample of FL nursing homes (approximately 140 homes). All these performance measures are multi-factor latent variables. Confirmatory factor analysis and data envelopment analysis are utilized to produce aggregate scores of these measures for each facility. We will perform multivariate modeling of the predictors of the best practice in nursing home care. The potential predictors include market (from ARF database), geographic, facility and resident characteristics. Statistically significant predictors of top nursing home performers will be incorporated in a decision support system for state government to adjust Medicaid reimbursement based on facility performance and nursing home administrators to improve their management strategies.
3. Resident Outcomes in Nursing Homes
Investigator: Patrick McNees, PhD
Public Affairs Doctoral Program, UCF
My major interests fall into the following areas: (1) chronic wound prevention and treatment; (2) resident activity patterns and physical and cognitive functioning, (3) non-medical approaches to improved clinical outcomes, and; (4) use of information and support technologies to affect clinical outcomes. A brief elaboration of each interest follows:
Chronic Wound Prevention and Treatment: Chronic wounds in general and pressure ulcers in particular are prevalent, costly and in the case of pressure ulcers, viewed as one marker of quality in LTC. While there is considerable evidence suggesting the clinical benefits of certain practices and treatment, these routines are not consistently followed in LTC facilities. I am interested in the identification of facility characteristics that employ and sustain evidence-based practice versus those that do not. I am also interested in systems that facilitate the use of evidence-based practice to improve wound healing outcomes. Systems that profile risk of developing a wound and provide decision support reducing the probabilities that wounds develop are also a research interest.
Resident Activity Patterns and Physical and Cognitive Functioning: Pilot work in
Non-medical Approaches to Improved Clinical Outcomes (Incidental Habilitation): There are many activities incidental to daily life that, if conducted appropriately, can impact clinical outcomes and improve resident life quality. We have been able to document decreases in incidents with injury, urinary tract infections, PRN medication use, psychotropic medication use and unplanned weight loss that were associated with such non-medical tactics. Unfortunately, most LTC facilities follow a medical task-oriented model that does not set the occasion for such activities.
Information and Support Technologies: While access to information is not typically sufficient for producing sustainable change, it is necessary component. I have a general interest in the use of technology for making information accessible, technologies that support clinical decision-making and technologies that provide ongoing feedback. I have a specific interest in remote monitoring and assessment as well as electronic triage systems for providing remote access to expertise.
4. Characteristics of Elder Abuse in Nursing Homes
Investigator: Kenneth Adams, Ph.D.
Public Affairs Doctoral Program
Elder abuse in residential care facilities is widely recognized as a serious problem. As a result of physical and mental disabilities, nursing home residents are particularly vulnerable to abuse from staff and residents. It can be expected that this problem will only grow worse given large projected increases in nursing home populations. Despite the gravity of the situation, little attention has been given to systematically studying the issues of elder abuse in nursing homes.
A major obstacle to the study of elder abuse in nursing homes is availability of information. The proposed research will combine several sources of data to provide a more comprehensive picture than previously has been available. In particular, incident reports from the Agency for Health Care Administration will be combined with data from the informatics network in
The analyses will focus on victim characteristics and organizational characteristics in relation to elder abuse incidents. Using epidemiological methods, it will be possible to develop a profile of residents who are at risk for abuse. These profiles should prove useful in the context of investigation, education and training. Also, by incorporating characteristics of nursing home facilities in the analysis, it will be possible to investigate hypotheses involving the relation of organizational features to rates of abuse. Since organizational characteristics can be manipulated and changed, this aspect of the research has potential for identifying ways in which abuse incidents can be prevented and rates of abuse can be lowered. Taken together, study of victim and organizational characteristics in relation to abuse of elderly residents in nursing homes can be used to improve the quality of care and service in these residential facilities.
5. Race and Ethnicity in Psychosocial Care Planning in Nursing Homes
Investigator: Denise Gammonley, Ph.D., L.C.S.W.
Specific Aims:
Responding to the concerns about racial/ethnic disparities in access to quality care in nursing homes this proposed project explores patterns of compliance with psychosocial care planning requirements as an indicator of quality care. Using a retrospective cohort design the study will examine associations between race/ethnicity and 1) the number of psychosocial care planning deficiencies noted in facilities; 2) the number and types of psychosocial service needs identified; and 3) the presence of a psychosocial care plan to address the psychosocial needs identified in an assessment.
Background and Significance:
Racial and ethnic differences in the utilization of nursing homes have been noted for some time (Mui & Burnette, 1995; Wallace, Levy-Storms, Kington & Andersen, 1998). Current analyses have associated these differences with contextual factors such as facility location and organizational factors such as case mix (Mor, Zinn, Angelelli, Teno & Miller, 2004). A recent HHS Inspector General study (2003) identified serious deficiencies in psychosocial care planning. Specifically, while almost all Medicare funded residents in SNF’s have at least one identified psychosocial care need nearly 40% do not have a care plan to address that need. Moreover, among those for whom a psychosocial care need is identified, only 54% actually receive their intended psychosocial services. Because of its ethnic and economic diversity
Design and Methods
Using administrative data from the Online Survey, Certification, and Reporting (OSCAR) and Minimum Data Set (MDS) resident assessment data for 14,000 facilities over seven years (1997-2004) the study will examine racial/ethnic variations using a systems framework and multinomial logistic regression techniques. Process factors serving as predictor variables will include the presence of a psychosocial care plan, psychosocial care planning deficiencies, and the number and types of psychosocial service needs identified. Racial/Ethnic category will serve as the outcome variable. Resident characteristics associated with psychosocial needs and organizational factors including facility case mix and social work staffing levels will serve as covariate control variables (Unruh & Wan, 2004).
References
Department of Health and Human Services (2003, March). Psychosocial services in skilled nursing facilities. Retrieved
Mor, V., Zinn, J., Angelelli, J, Teno,
Mui, A. & Burnette, D. (1994). Long-term care service use by frail elders: is ethnicity a factor? The Gerontologist, 34(2), 190-198.
Unruh, L. & Wan, T.T.H. (2004). A systems framework for evaluating nursing care quality in nursing homes.
Journal of Medical Systems, 28(2), 197-214.
Wallace, S.P., Levy-Storms, L., Kington, R.S., Andersen, R.M. (1998). The persistence of race and ethnicity in the use of long-term care. Journals of Gerontology: Psychological Sciences and Social Sciences, 53(2), S104- S112.
6. Disparities among Minorities with Cognitive Impairment in
Investigator: Maxime Gagnon, Ph.D.
Public Affairs Doctoral Program, UCF
Background
Over the past 30 years, approximately 20 117 163 million immigrants have arrived in
Objectives
The objectives of this research are 1) to describe the functional status of newly-admitted nursing home minorities; 2) to assess cumulative incidence and cognitive factors predicting nursing home placement in elder minorities; 3) to assess the evolution of cognitive impairment of minorities as compared to white Americans over time and 4) to predict the factors related to the access and the quality of care for the minorities with cognitive impairment over time. Some of the problems identified in conducting research on the cognitive impairment of ethnic groups have been addressed using cross-sectional methods. Longitudinal studies should be used to provide rich information on the cognitive performance of immigrants over time. A longitudinal study could be helpful to explore the trajectories of factors associated with deterioration of cognitive performance of minorities in nursing homes and their impact on the quality of care offer by the nursing staff. Longitudinal studies have to be used to provide rich information on the cognitive impairment of minorities and their determinants over time.
Method
The study will use an administrative dataset (MDS, Minimum Data Set) compiled from a panel of 14,000 facilities in 1997-2003. Multivariate statistical modeling techniques will be used to analyze the seven waves of data. Specifically, we will use the Cognitive Performance Scale (CPS) scores.
Conclusion
Residents with undocumented cognitive impairment were significantly less likely to be evaluated for reversible causes. Research is needed to determine if better documentation of cognitive impairment would improve not only diagnostic evaluations but also patient management, counselling, outcomes and quality of care for minorities in nursing homes.